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Patient Registration Form

Please fill out the below patient registration form or download a copy here and bring it with you to your first appointment.





Patient Details

Title
First Name
Last Name
Date of Birth

Address
Suburb
State
Postcode

Email Address
Mobile Phone
Home Phone
Work Phone

Medicare Details

Medicare Number
Ref Number next to name
Expiry Date


Parent/Carer Details If Patient is a Minor

First Name
Last Name
Date of Birth
Medicare Number

Next of Kin/Emergency Contact

Name
Relationship
Contact Number

Private Health Fund Details

Level of Cover


Private Health Fund Name
Private Health Fund Membership Number

Dept of Veterans Affairs Details

DVA Card
DVA Card Number
DVA White Card Approved Condition

Referring Doctor Details

Referring Doctor’s Name
Clinic Suburb
GP Name (if not referrer)
Clinic Suburb

SMS Appointment Reminder

Do you wish to receive appointment reminders via SMS?



Privacy Information

To enable the ongoing provision of care within this practice, and in keeping with the Privacy Act 1988 and Australian Privacy Principles (APPs), we wish to provide you with information on how your personal and health information may be used or disclosed.

WestsideENT collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs.

Your personal and health information will only be used for the purposes for which it is collected, or as otherwise permitted by law.


Consent

I have read the information above and understand the reasons why my information must be collected. I am also aware that WestsideENT has a Privacy Policy on handling patient information which is displayed on its website.


I consent to the use of my personal and health information by WestsideENT and other health providers involved in my medical care. I consent to the disclosure of my personal and health information by WestsideENT to other health providers directly or indirectly involved in my personal health care or medical treatment.


I give my consent to WestsideENT to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information, to WestsideENT as may be requested.



Medical Information

Medical Conditions (Please tick all that apply)


High blood pressureStrokeHeart AttackCardiac Bypass SurgeryCardiac StentsTIABlood Clots / Pulmonary Embolism / DVTAsthmaDiabetesChronic lung disease/COPDAtrial Fibrillation


Bleeding Disorders

Do you have a history of any bleeding diseases?

Is there a family history of any bleeding diseases?

Do you take any of these medications?


Current Medications


Allergies


Smoking & Alcohol History

Smoking Status
No of years smoking
No of cigarette per day
Quit Date


Do you drink alcohol?
Drinks per week

BOOK AN APPOINTMENT

Call us at 07 3202 4636

or
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WestsideENT is an ear, nose, and throat specialist practice whose members provide leading expert care for adults and children.
Dr Craig Bond, Dr Stephen Kelly and Dr Chris Oosthuizen are our ENT surgeons who provide specialist care to the communities of south west Brisbane, Springfield, Ipswich and surrounding regions.

Copyright Westside ENT 2019. All rights reserved.